Event Notification Report for April 11, 2024

AGREEMENT STATE REPORT - RECEIVED DOSE LESS THAN PRESCRIBED

The following information was received from the Georgia Department of Natural Resources (GADNR), Georgia Radioactive Materials Program, via email:

"On Monday April 1, 2024, GADNR received notification from our licensee, [license number] GA 796-1, of a brachytherapy seed migration post implant of Iodine-125 seeds. The reporting official is the hospital's Manager of Radiation Physics [MRP]. [The MRP] was contacted via cell phone today, April 2, 2024, for further information. [They] stated that each seed was approximately 0.635 mCi, totaling 18.62 mCi. The patient was seen some time last week and their computed tomography (CT) results were analyzed yesterday during their post implant CT exam. The prescription was 145 Gy to the prostate using 18.62 mCi of I-125. The D90 to the target was 46.2 percent instead of the expected 80-120 percent on the post implant dosimetry. [The MRP] will be sending a full report of this incident within the next 15 days. [GANDR] will follow up with more information at a later date."

* * * RETRACTION ON 4/9/24 AT 0807 EDT FROM ANASTASIA BENNETT TO BILL GOTT * * *

The following information was received from the Georgia Department of Natural Resources (GANDR), Georgia Radioactive Materials Program, via email:

"GADNR is requesting closure of the incident case as it does not meet the reporting criteria outlined in 10 CFR 35.3045(a)(2)(i)(2) for permanent implant brachytherapy. Specifically, the incident does not involve the administration of byproduct material or radiation from byproduct material resulting in a total source strength administered differing by 20 percent or more from that documented in the post-implantation portion of the written directive, excluding instances where sources migrate outside the treatment site."

Notified R1DO (DeFrancisco) and NMSS Events Notification via email.

Georgia Incident number: 83

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

AGREEMENT STATE - LOST PACKAGE

The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:

"On March 4, 2024, the Agency received a notification from G.E. Healthcare in Arlington Heights, IL to advise of one missing radiopharmaceutical package at the Memphis, TN [common carrier] hub. The package contained one vial of I-123 with 14.268 mCi at the time of shipment.

"G.E. Healthcare was notified on March 4, 2024 by [common carrier] in Memphis, TN that a radiopharmaceutical package was missing with no indication of the contents being separated from the package. The package was originally shipped out of G.E. Arlington Heights, IL facility on February 29, 2024. The lead shielded package contained 14.268 mCi of I-123 in one 10 mL vial at the time of shipment. The destination was Spokane, WA. The last measured activity was 0.094 mCi. The last scan was at the [common carrier] hub in Memphis on February 29, 2024 and [common carrier] confirmed the package could not be found on March 4, 2024. This matter will continue to be tracked until an update is available or the package has decayed to background levels.

"As of April 3, 2024, the licensee indicates there are no changes to the status of the package or contents of the package. The package content has decayed to background levels. This does not pose a threat to the health and safety of the public. Provided there are no changes, this matter is considered closed."

Item number: IL240007

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

AGREEMENT STATE REPORT - LOST SOURCE

The following information was received via email by the Illinois Emergency Management Agency (the Agency):

"Annual self-inspection request was sent to all generally licensed entities on February 15, 2024. This registrant e-mailed back on February 21, 2024, indicating that he was no longer associated with the company, the company was no longer in business in Illinois, and the radioactive material was lost. The company was sold and the radioactive material was sold with the other assets. However, the sources were in place as recently as January 3, 2020, when they submitted their last self-inspection.

"The registration had three 10 mCi nickel-63 (Ni-63) sealed sources on their inventory. After continued research, the Agency was unable to track down the sources. The Agency contacted the manufacturer, Shimadzu, who did not have any records of any service work on the 3 sources or disposal paperwork. The new company could not be found. These sources do not pose a health or safety risk to the public. Pending any new information, this matter is considered closed."

Illinois Item Number: IL240005

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

STUCK SHUTTER

The following information was provided by the licensee via phone:

The radiation safety officer (RSO) was showing a new employee the nuclear gauges when they noticed that a gauge was missing a handle. The handle opens and closes the shutter. The RSO believes the shutter may be stuck in the open position. The gauge was manufactured by Burthold in 1995 with model number 7440 and serial number 2964 containing 50 millicuries of Cs-137. There is no additional exposure to plant personnel or the public due to the position of the shutter. Burthold has been contacted for maintenance.

AGREEMENT STATE REPORT - STUCK WELL LOGGING SOURCE

The following information was provided by the Louisiana Radiation Protection Division (the Division) via email:

"On April 4, 2024 at approximately 1619 CDT, the president and radiation safety officer (RSO) of Roke Technologies USA, Inc. [was] working under Louisiana reciprocity when they reported to the Division that at approximately 1400 CDT, two QSA Global 3.0 Ci well logging sources of Americium-241:Be (Model AMN.CY3) contained in the licensee's custom made proprietary logging tool became stuck in tubing at a depth of approximately 1,965 feet. The well, Ronald Richard et ux No. 1, is in Opelousas Field, St. Landry Parish, Louisiana. The E-line holding the logging tool, rated at 3,150 lbs., pulled out of the rope socket on the logging head after the subcontractor logging crew, Verde Services, LLC (Verde) of Laurel, MS, attempted to pull out the tool. The licensee's plan is to meet Verde's braided line truck that is arriving on site at 0800 CDT on April 5, 2024. The braided line is much stronger than the E-line and this truck has a greater pulling strength than the E-line truck. The licensee has high confidence that they will be able to recover the tool as they are also equipped with a fishing neck for the 1-11/16-inch tool which faces upward inside the 2-3/8-inch tubing. The RSO is remaining on site until the tool and sources are recovered. The RSO will follow up with a status report tomorrow morning."

PART 21 - INTERIM REPORT FOR UNVERIFIED CRITICAL CHARACTERISTICS OF DARMATT KM-1 FLAT BOARD

The following is a summary of the information provided by Transco Products Inc. via email:

10 CFR Part 21 Initial Notification: TPI-LTR-2024-01-01-0

On November 16, 2023, during an audit review, it was determined that the dedication plan was inadequate. The dedication plan lists chemical properties as one of the critical characteristics with the acceptance criteria. The extent of condition is limited to Darmatt KM-1 flat board supplied to Energy Northwest (Columbia Generating Station). The issue has been entered into Transco Products Inc.'s corrective action program. Testing to verify the chemical properties of the supplied flat board is in process. Energy Northwest was the only impacted licensee and they have been notified.

Notified R4DO (Azua) and Part 21 Group via email.

FITNESS FOR DUTY

The following information was provided by the licensee via email and phone call:

"A non-licensed employee supervisor had a confirmed positive during a random fitness-for-duty test. The employee's access to the plant has been terminated.

"The NRC Senior Resident Inspector has been notified."